Outcomes and Complications of Bronchial Angioembolization in Patients with Massive Hemoptysis

Background: Massive hemoptysis is a potentially life threatening medical condition and one major problem for both patients and physicians. Choosing the appropriate treatment for the patients is crucial in order to decrease the complications and increase the success rate. Hence, in this study the outcomes and complications of bronchial angioembolization (BAE) were determined in patients with massive hemoptysis. Materials and Methods: In this prospective cohort, 189 consecutive patients with moderate and severe hemoptysis who had referred to two large cardiovascular centers were enrolled. The Chest X Ray, CT Scan, Fiberoptic Bronchoscopy, Selective and Nonselective Bronchial Angiography were performed in patients. The outcomes with 20-month follow-up were compared. Results: The immediate success rate was 97.3%. In 79.7% there were no complications. Temporary chest pain, subintimal dissection, temporary dysphagia, and pancreatitis were seen in 12.3, 2.4, 5.1, and 0.5%, respectively, without any major complication. The in-hospital mortality rate was 1.1% and mortality during 20-month follow-up was 9.6%, and recurrence rate was 28.3% on total. Conclusion: Our case series showed that BAE is a safe and effective method in treating patients with hemoptysis. Compared to surgery, the procedure is faster and less invasive and might be used both as first line or bridging therapy. Importantly, no major complications have been detected.


INTRODUCTION
Hemoptysis is the coughing up of blood or bloody sputum from respiratory tract originating from below the vocal cord (1). It is a concerning issue for both patients and physicians because of life threatening situation and serious etiologies such as malignancy (2). While mild hemoptysis is discontinued spontaneously in vast majority of cases, massive hemoptysis may be a life-threatening problem (3).
Massive hemoptysis is defined as coughing up of massive bloody sputum (more than 240 to 300 ml) in 24 hours. It is a critical condition with case fatality rate of nearly fifty percent (4,5).
The etiologies for hemoptysis are currently changed from tuberculosis, bronchitis, and bronchiectasis to malignancy (6)(7)(8). Treatments are also different according to the background etiologies (9

Bronchial Angioembolization (BAE)
In non-emergency situation, before the embolization, culprit vessel is routinely identified in the CT angiography.
In addition, the best working view of each bronchial artery is also determined. In contrary, in emergency situation patient's condition do not usually allow for preprocedural imaging. In this group of patients saving airways is of utmost importance and thus anesthesiologist consultation is mandatory. from 500 µm to 900 µm. All patients were followed for 24 months.

Statistical analysis
All the statistical analyses were performed using SPSS software, version 23.0, (SPSS, Inc, Chicago, IL, USA). All the tests were 2-tailed, and the differences were reported as significant if the P value was less than 0.05. The Kolmogorov-Smirnov test was applied to evaluate the normal distribution of the data. The normally distributed continuous data, expressed as the mean ± the standard deviation (SD), were analyzed using the Student t-test, the χ 2 test, or the Fisher exact test. The continuous variables were compared between the 2 groups and in each group before and after the intervention by using the independent t-test and the paired sample t-test, correspondingly.

DISCUSSION
Traditionally surgery is considered as the ultimate therapy for hemoptysis. However, it is accompanied by high morbidity and mortality and the success rate is limited (9). Bronchial angioembolization is an emerging therapy, which allows a rapid and selective control of bleeding and with least morbidity and mortality (10,11). In the present study we have reported our result of bronchial angioembolization in 189 patients that referred to two large cardiovascular centers in Iran.
In our study, the main cause of massive hemoptysis was bronchiectasis followed by tuberculosis, aspergillus pneumonia and pulmonary hypertension, while worldwide, malignancy is the main reported etiology (6)(7)(8).
During our study we reached a success rate of 97.3% and recurrence rate of 28.3 % which is quite acceptable compared to global experience (12)(13)(14)(15)(16)(17)(18)(19)(20). In a systematic review performed by Panda et al (12) were the most common etiologies in their studied population. BAE was successful in all patients and no major complication has been encountered (19).
In conclusion, our study showed that bronchial angioembolization is considered a safe and effective approach in the treatment of patients with massive hemoptysis. The procedure success has a close relation with operator's skill, bronchial anatomy and hemoptysis etiology. BAE might be considered an acceptable alternative therapy compared to surgery. However, further studies with larger sample size are required to attain more definite results.